Breath-holding spells (BHS) are involuntary events seen in young children, typically occurring between six months and six years of age, with peak frequency around 12 to 18 months. These episodes are reflex actions of the nervous system, not intentional attempts by a child to manipulate a caregiver. They most often follow intense emotional upset, pain, or sudden shock, causing a temporary disruption in breathing and sometimes a brief loss of consciousness. BHS are a common, benign phenomenon, affecting up to 5% of otherwise healthy children. The spells are usually brief, lasting less than a minute, and do not cause any long-term health issues.
Understanding the Two Primary Types of Spells
The two primary types of breath-holding spells are classified based on the child’s appearance during the event.
Cyanotic spells are the most common type. These spells are typically triggered by anger, frustration, or intense crying, resulting in a temporary lack of oxygen. During a cyanotic spell, the child cries vigorously, then suddenly holds their breath, causing the skin, especially around the lips, to turn a bluish or purplish color. The child may then go limp and lose consciousness briefly before quickly regaining normal color and awareness.
Pallid spells are less frequent and are usually a reaction to sudden pain, fright, or a startling event. This type is characterized by a temporary slowing of the heart rate, a response mediated by the vagus nerve. The child’s face becomes noticeably pale or ashen, and they may pass out with minimal or no preceding crying.
Common Triggers and Underlying Causes
Breath-holding spells are generally precipitated by an emotional upset, such as being scolded or disciplined, or by physical discomfort like a minor fall or injury. Cyanotic spells are typically triggered by anger or frustration, while pallid spells are more often associated with the sudden emotional or physical shock of pain or fear.
The underlying cause of BHS is a temporary, involuntary reflex of the autonomic nervous system. In cyanotic spells, prolonged breath-holding leads to a temporary lack of oxygen reaching the brain. In pallid spells, the sudden shock causes a vasovagal response, a reflex that significantly slows the heart rate and blood flow to the brain, leading to pallor and fainting. Iron deficiency anemia has also been identified as a possible contributing factor.
How to React During an Episode
The most important action during a breath-holding spell is ensuring the child’s safety from injury. If the child loses consciousness, immediately lay them flat on their back or side on a safe surface, such as the floor or a crib. This position helps blood flow return to the brain, shortening the duration of unconsciousness.
Check for anything in the child’s mouth that could cause choking, but do not attempt to put anything, including your fingers, inside their mouth. Caregivers should remain visibly calm and avoid overreacting, as excessive attention may inadvertently reinforce the behavior that triggered the spell. The spell is an involuntary reflex, and the child will automatically resume breathing within a minute or two.
After the spell resolves, treat the child as you normally would, without punishment or excessive coddling. If the spell lasts longer than a minute, or if the child stops breathing or cannot be woken up, seek emergency medical help.
Medical Evaluation and Long-Term Outlook
A medical consultation is recommended, especially after the first episode, to confirm the diagnosis. The evaluation helps rule out other, more serious conditions that can mimic BHS, such as certain cardiac issues or seizures. A doctor may perform blood tests to check for iron deficiency anemia.
It is common for parents to worry that BHS are a form of seizure, but they are distinct events, although stiffening or brief jerking movements can sometimes occur during a prolonged spell. Neurological testing, such as an electroencephalogram (EEG), is typically normal in children with BHS.
Children almost always outgrow the condition, with most spells resolving spontaneously by the time the child reaches five or six years of age. In rare cases, individuals who had pallid spells in childhood may have an increased risk of vasovagal syncope, or fainting, as adolescents or adults.